Diabetic eye exam intake that captures retinopathy history up front
Patients complete a guided intake that captures diabetes diagnosis status, current vision changes, and prior retinopathy history, plus insurance and referral details, so staff can see who actually needs a diabetic eye exam before a slot is booked.
Preview your diabetic eye exam intake
Explore 5 questions from the Diabetic Eye Exam template. This interactive preview uses illustrative scoring and sample attachments. Open the full survey to try the complete intake.
What a qualified diabetic eye exam lead should tell you
A dilated eye exam for people with diabetes to screen for diabetic retinopathy and related complications, using diagnosis status, current vision symptoms, and prior exam or retinopathy history to determine how soon the patient needs to be seen.
- Been Diagnosed With Type
- Experiencing Any Vision Changes,
- Was Last Dilated Eye
- This Exam
- Doctor Previously Told That
The questions your team needs answered
Every diabetic eye exam intake asks these — and why each one matters.
| Question | Why it matters |
|---|---|
| Have you been diagnosed with type 1 or type 2 diabetes? | A confirmed diabetes diagnosis carries the highest weight in this catalog, since it establishes clinical eligibility for the exam itself. |
| Are you currently experiencing any vision changes, such as blurriness or dark spots? | Current vision changes are weighted almost as heavily as diagnosis status, so this answer meaningfully raises a lead's score even before staff review the chart. |
| When was your last dilated eye exam? | Knowing whether the patient has never been screened or is overdue helps staff prioritize scheduling without needing to call the patient first. |
| Who is this exam for? | This clarifies whether the diagnosis and symptom answers describe the submitter or someone else, which prevents scheduling mix-ups for caregiver-submitted leads. |
| Has a doctor previously told you that you have diabetic retinopathy or other eye damage? | A prior retinopathy diagnosis adds clinical context that helps staff judge how soon the patient should be seen relative to a first-time screening. |
How Cliont scores diabetic eye exam leads
Configured answer weights help your team prioritize follow-up. Your team reviews each submission and decides the next step.
Value signals
- Been Diagnosed With Type: yes
- Experiencing Any Vision Changes,: yes
See an example lead handoff
Illustrative lead details and score show how a submission can reach your team.
Diabetic Eye Exam Lead
From first click to qualified lead
Follow patients and caregivers through one smooth, guided flow.
They land & meet you
Your video greeting plays instantly — a real face instead of a blank form.
They explain the visit
Smart questions adapt to their visit and capture the full scope.
They share details
Symptoms, history, and documents come attached before the visit.
You get a ready lead
Scored and qualified — waiting for you to win it.
Built for diabetic eye exam workflows
| Cliont capability | Diabetic Eye Exam application |
|---|---|
| Weighted scoring engine | Applies the highest weights to confirmed diabetes diagnosis and reported vision changes, so a patient with both answers ranks above a routine annual recheck in your CRM. |
| Branching answer logic | Keeps the 'who is this exam for' answer tied to the diagnosis and vision-change responses, so caregiver-submitted leads describe the actual patient, not the person filling out the form. |
| CRM lead routing | Sends the patient's diagnosis status, last dilated exam timing, and prior retinopathy history into your CRM as structured fields staff can filter and sort by. |
| Document upload capture | Collects insurance details and any referral letter alongside the intake answers, so front desk staff aren't chasing paperwork after the appointment is already booked. |
Example diabetic eye exam lead scenarios
Illustrative situations explain the intake questions and possible follow-up.
Newly diagnosed, never screened
Patient confirms a type 1 or type 2 diagnosis and selects 'Never had one' for their last dilated exam, which lifts the score on both weighted fields and signals a first-time screening is overdue.
Established diabetic reporting vision changes
Patient with a known diabetes diagnosis also reports blurriness or dark spots, combining both high-value answers so the lead stands out from routine rechecks in the CRM queue.
Caregiver booking for someone else
The person completing the form selects 'Someone I care for' or 'A family member,' so the diabetes and vision-change answers describe the actual patient rather than the submitter.
Overdue patient with prior retinopathy
Patient confirms a doctor previously identified diabetic retinopathy but their last dilated exam was more than two years ago, flagging a monitoring gap for staff to review directly.
Uncertain history, no diabetes diagnosis
Patient answers 'no' to diabetes and 'not sure' on last exam timing, which still routes to the CRM but with lower weighting so staff can confirm fit before scheduling.
Connect Cliont to your workflow
Connect your CRM
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Lawmatics, MyCase, Clio Manage and Clio Grow
Notify your team
Email, SMS, Slack
Configure other destinations
Google Sheets, configured webhooks, Zapier and API workflows
Simple, transparent pricing
Choose the plan that works for your business.
Professional
Unlimited intake forms and leads for your growing business.
- Unlimited intake forms
- Custom video greetings
- AI-powered voice bot
- English + Spanish support
- Automatic lead scoring
- Digital estimates & e-signatures
- Photo, video & file upload
- Advanced analytics dashboard
Pay Per Lead
Only pay when you receive a qualified lead.
- Unlimited intake forms
- Custom video greetings
- AI-powered voice bot
- English + Spanish support
- Automatic lead scoring
- Digital estimates & e-signatures
- Photo, video & file upload
- Charged only for submitted leads
More ophthalmology intake templates
Diabetic Eye Exam lead-intake FAQs
How does the intake decide which diabetic eye exam leads get priority?
The diagnosis question and the vision-changes question carry the highest weights in this catalog, so patients who confirm both a diabetes diagnosis and current symptoms score higher and surface first in your CRM. Staff still make the final scheduling call.
What if a patient doesn't remember their last dilated eye exam?
The 'Not sure' option is a valid answer, not a dead end. It's captured and delivered with the rest of the record so staff can follow up rather than the form blocking submission.
Can someone submit this intake on behalf of a parent or patient they care for?
Yes. The 'Who is this exam for' question covers a family member or someone the submitter cares for, and that context stays attached to the lead record so scheduling isn't confused with the submitter's own eligibility.
Does reporting blurriness or dark spots make the intake flag a medical emergency?
No. That answer increases the lead's score because it's a value signal in this catalog, but the intake doesn't make a clinical urgency determination — your staff review the actual symptoms reported.
How is this different from the Comprehensive Eye Exam intake?
This form specifically screens for diabetes diagnosis status and prior retinopathy findings, which the Comprehensive Eye Exam intake doesn't ask about, so the two lead types arrive in your CRM with different context.
What happens if a patient says they don't have diabetes?
That answer carries a lower weight but isn't treated as disqualifying — the lead is still captured and routed so staff can confirm whether the exam is still appropriate.
Turn diabetic eye exam visitors into qualified patients
Give every diabetic eye exam visitor a guided intake instead of a dead contact form — and get a scored, qualified lead before you book front-desk time.